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Mitigate Risk in Your Emergency Department

By Dawn Isaacs, Health Care Consulting Practice, Moss Adams
By Pat Oungpasuk, Health Care Consulting Practice, Moss Adams

See all this Month's Articles

Original Publish Date: January 16, 2024

In the post-pandemic world, the health care system remains at or over capacity, leaving many organizations struggling with how to meet patient demand.

Some of the primary issues plaguing the system include:

The emergency department (ED) is an open door for those in need of health care, and overcrowding has become the norm.

Overcrowding inside the ED causes additional risks for a health care organization, including lack of quality and safe care, regulatory violations, patient dissatisfaction, low staff engagement, physician dissatisfaction, and more.

Throughput and Left Without Being Seen

One key issue that causes EDs to be overcrowded is throughput within the department. Throughput in an ED is defined as time of arrival to time of dismissal—and the key driving metric within that timeframe is door to doctor. Simply, how long after a patient arrives at the ED does it take for the provider to perform their first evaluation?

The current national average for time patients spend in the ED prior to discharge is approximately 180 minutes, with leading practices closer to 150 minutes. This number can be slightly different based on the organization’s annual number of visits. However, often organizations that successfully manage their ED length of stay can mitigate some of the risk of overcrowding.

Another risk caused by overcrowding in the ED is patients that leave prior to being medically screened by a provider or before their treatment is complete. This can cause two issues:

In addition to serious health implications and consequences to the patient, these scenarios can also have a significant financial impact to the organization if the exacerbated illness requires a longer length of stay (LOS) and potentially damage the organization’s reputation.

Solution: Evaluate Your LOS Metrics to Uncover Improvement Opportunities

One of the potential solutions to improving an ED’s LOS and LWBS rate is to evaluate the metrics related to LOS. Suggested data elements to review include:

Focusing on these improvement opportunities would also require a review of workforce and labor to ensure staff are scheduled appropriately at peak times. Additional workflows to consider include assessing use of provider in triage, nurse standing orders, and the fast track process.


Inpatient ED holds, or boarding, also plays a significant role in overcrowding inside the ED. Patients not yet admitted and waiting for an empty bed are often held in the ED. In some organizations, patients may wait longer than 24 hours and at times will be discharged from the ED, having never received a bed. Staffing, continuity of care, and space are the underlying risks when ED boarding issues occur in long intervals.


To mitigate boarding issues, organizations should review ED admission rates by specialty in their organization and compare those rates to the national rate—approximately 22%.

Organizations should also ensure their hospital has a surge capacity plan that proactively aligns nursing units and ancillary departments when the ED is at high volume. Some examples of the surge plan include:

As throughput metrics within the ED improve, incidental improvements will also occur with patient satisfaction, staff satisfaction, and a decrease in number of patient grievances.

For long-term and sustainable success, ED physicians, hospital leadership, and staff within the ED all need to be involved to drive the solutions and implement change. Active team members should monitor these metrics closely and evaluate on a routine basis to ensure the organization is not at risk and able to provide timely care to those in need.

Dawn Isaacs is a registered nurse and provides clinical expertise and operational guidance to organizations. She can be reached at or (206) 834-8756.

Pat Oungpasuk has worked in both hospital consulting and health policy. She can be reached at or (925) 952-2528.

Assurance, tax, and consulting offered through Moss Adams LLP. ISO/IEC 27001 services offered through Moss Adams Certifications LLC. Investment advisory offered through Moss Adams Wealth Advisors LLC.